HAZARD REPORT FORM

PART A: HAZARD IDENTIFICATION – TO BE COMPLETED BY WORKER

Workers Name:_______________________________________ Time Reported: / am / pm Date: / /

Workers Supervisor: ___________________________________________________________________________________
Exact Location of Hazard: _______________________________________________________________________________
Description of Hazard: __________________________________________________________________________________
____________________________________________________________________________________________________
Workers Suggested Solution to control the Hazard:____________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Worker’s Signature:_____________________________________________________________________________________

PART B: TO BE COMPLETED BY SUPERVISION

Hazard Investigation Found:_____________________________________________________________________________
_____________________________________________________________________________________________________
Can Hazard be Eliminated Immediately?
YES Supervision to eliminate Hazard and signoff Part B then forward to Health and Safety Representative.
Describe Actions Taken:__________________________________________________________________________________
_____________________________________________________________________________________________________

NO Supervision to Assess Hazard and determine Risk level (Refer to Risk Assessment Matrix)
Risk Rating Hierarchy of Control Used: (one or combination)

Extreme: Stop work until risk control implemented Substitution

High: Implement risk control within 3 days Engineering
Moderate: Implement risk control within 1 week Administration Safe Operating Procedure / Training
Low: Regularly monitor hazard Personal Protective Equipment

Risk Control Measure Action Plan: Supervision (in consultation with worker) determines and implements risk controls.

Action Responsibility Target Date Completed

Are Controls Completed and Assessed? YES Do Not pass on unless risk has been Satisfactorily Controlled!
Feedback to Worker who raised Hazard Report Form? YES

Supervisor’s Signature: ______________________________________________________________Date:_________________

PART C – TO BE COMPLETED BY SAFETY OFFICER

Hazard has been Assessed and Controlled
Name:__________________________ Signature:________________________________________
Date:_________________

PART D – TO BE COMPLETED BY PROJECT/CONSTRUCTION MANAGER

 HAZARD REPORT FORM

Hazard has been Assessed and Controlled to my satisfaction

Manager’s Signature: _______________________________________________________________

Date:_________________